Provider Demographics
NPI:1245254499
Name:OMALLEY, MICHAEL ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:OMALLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 ROBIN PL
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-7505
Mailing Address - Country:US
Mailing Address - Phone:530-757-3233
Mailing Address - Fax:
Practice Address - Street 1:501 OAK AVE
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-3624
Practice Address - Country:US
Practice Address - Phone:530-757-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42283207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF68660Medicare UPIN